Catheter ablation in AF patients with heart failure. What is possible?
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1 Catheter ablation in AF patients with heart failure What is possible? Sébastien Knecht, MD PhD Hôpital cardiologique du Haut L Evêque, Bordeaux
2 HEART FAILURE AND AF Ehrlich. JCE 2002 (13): ,
3 Wang et al. Circulation 2003 HEART FAILURE AND AF AF subjects: new CHF increases mortality CHF subjects: development of AF increases mortality Preexisting CHF adversely affects survival in AF pts but preexisting AF does not affect survival in CHF pts
4 DRUGS EFFICACY AAD use in Rhythm group 82% and 73% after 12 and 36 months respectively 21% cross-over Periodic ECG monitoring Significantly less betablocker use in Rhythm group AF-CHF Study. N Engl J Med 2008;358:
5 Rhythm versus rate control SR : 47% reduction in mortality AAD : 49% increase in mortality CHF : 57% increase in mortality Current AADs are not associated with improved survival, suggesting their beneficial antiarrhythmic effects are negated by their adverse effects Circulation 2004
6 AF ABLATION EFFICACY Jais et al. CIrcultion 2009
7 HEART FAILURE AND AF 94/377 pts with LVEF< 40% Parox AF: 43% SHD: 91% Chen et al, JACC 2004, 43,
8 AF ablation in patients with HF Hsu. N Engl J Med 2004;351:
9 AF ablation in patients with HF Hsu. N Engl J Med 2004;351:
10 Rate control Heart Disease LV Ejection Fraction (%) Poor Rate Control +23±10 % P<0.001 P<0.001 Adequate Rate Control +17±15 % LV Ejection Fraction (%) No concurrent heart disease +24±10 % Concurrent heart disease +16±14 % P<0.001 P< ± ±7 Months Months Hsu. N Engl J Med 2004;351:
11 AF ablation in patients with HF 72% Recurrence of arrhythmia despite the use of antiarrhythmic drugs was the only variable negatively affecting the recovery of the LVEF Hsu. N Engl J Med 2004;351:
12 Improvement in exercice capacity after ablation min 14 Exercise Time W 145 Max Power Attained 13 P= P= ±7 0 11±7 Months Months Based on 58 pts published in NEJM 2004; 351, Hsu. N Engl J Med 2004;351:
13 Effect of PVI on LV EF LVEF % 44% LVEF Baseline LVEF Follow up Follow-up: 20 ± 9 months. 67 patients (70% PAF) EF 50% HR<90 bpm LV EF increased by > 5% in 82% patients LV EF normalized to 55% in 72% patients Gentlesk, Marchlinski et al, JCE
14 Effect of PVI on LV EF 47% 105 patients (25% PAF) 40 CHF (LVEF < 40%) 65 normal LVEF 33% P<0.01 LV EF increased from 33% to 47% after ablation Improvement in exercise capacity and QOL Follow-up: 14 ± 2 months. No tamponnade nor stroke Tondo et al, PACE 2006
15 AF ablation vs. biventricular pacing +AV node ablation for treatment of AF in CHF PABA-CHF Khan, Natale NEJM 2008
16 HEART FAILURE AND AF Khan et al. PABA study. NEJM 2008
17 HEART FAILURE AND AF After PV isolation Khan et al. PABA study. NEJM 2008
18 AF ablation vs. biventricular pacing 6 month follow up In the ablation group, 88% with drug and 71% without drugs were free of AF Khan et al. PABA study. NEJM 2008
19 HEART FAILURE AND AF PABA study. NEJM, in press
20 AF ablation and mortality EF>40, SR EF<40, SR EF>40, AF EF<40, AF (Years) Nademanee. J Am Coll Cardiol 2008;51:843 9
21 Outcome of AF ablation in CHF N Chronic AF Repeat Ablation Sinus Rhythm LVEF Pre LVEF Post Chen/Natale JACC 2004 Hsu/Haissaguerre NEJM 2004 Tondo PACE 2006 Gentlesk/Marchlinski JCE 2006 Lutomsky/Willems Europace 2008 Nademanee JACC 2008 PABA-CHF NEJM % 22% 96% 36±7 41± % 50% 78% 35±7 56± % 33% 87% 33±2 46± % 1.6 proc 86% 42±9 56±8 18 0% 0% 50% 41±7 52± % 48% 79% 31±7 41± % 19% 71% 27±8 35±9
22 Meta-Analysis: Persistent AF Ablation / Heart Failure Need for substrate modification Single procedure success = Comparable among techniques (47%) (Inferior exceptions: Small PVI ablation, CFAE only ablation) Success rate improves with repeat procedures (65%; 1.4 procedures) and/or previously ineffective drugs (79%). Brooks AG et al. Heart Rhythm. 2010;7:
23 Until AF termination and SR restoration Stepwise approach PV isolation Electrogram based ablation LA linear lesions AT ablation
24 AF Permanent for months terminated in 87% (60 pts) Cumulative AF Termination 5% 25% 53% 87% Random Steps: PVI Egm LA&CS Lines Incremental benefit of each step for AF Termination WHATEVER THE ORDER OF TARGETS JCE nov 05
25 AFCL LEFT ATRIUM LAA CORONARY SINUS
26 Monitoring during ablation 220 Conversion to AT 200 AFCL Prolongation Mapping and ablation to sinus rhythm Haïssaguerre et al. Europace 2008
27 HYPOTHESIS CONCERNING THE AF CL Elements «at work» Number of elements ERP AF CL
28 PRONOSTIC V1 Matsuo et al. JACC 2009
29 PRONOSTIC Matsuo et al. JACC 2009
30 Conclusions AF ablation has to be envisaged in CHF patients with AF The stepwise approach used for AF ablation is associated with a good success rate in CHF patients In CHF patients, successful AF ablation results in dramatic improvements in symptoms, exercise capacity and quality of life The best candidates are patients with tachycardiomyopathy related to AF
31 Conclusions AF ablation has to be envisaged in CHF patients with AF The stepwise approach used for AF ablation is associated with a good success rate in CHF patients In CHF patients, successful AF ablation results in dramatic improvements in symptoms, exercise capacity and quality of life The best candidates are patients with tachycardiomyopathy related to AF
32 Conclusions AF ablation has to be envisaged in CHF patients with AF The stepwise approach used for AF ablation is associated with a good success rate in CHF patients In CHF patients, successful AF ablation results in dramatic improvements in symptoms, exercise capacity and quality of life The best candidates are patients with tachycardiomyopathy related to AF
33 Conclusions AF ablation has to be envisaged in CHF patients with AF The stepwise approach used for AF ablation is associated with a good success rate in CHF patients In CHF patients, successful AF ablation results in dramatic improvements in symptoms, exercise capacity and quality of life The best candidates are patients with tachycardiomyopathy related to AF
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